Echocardiographic predictors of adverse short-term outcomes after heart surgery in patients with mitral regurgitation and pulmonary hypertension.

BACKGROUND: Pulmonary hypertension (PH) is a frequent occurrence and a negative prognostic indicator in patients with mitral regurgitation. Preoperative PH causes higher early and late mortality rates after heart surgery, adverse cardiac events, and postoperative systolic dysfunction in the left ventricle (LV). METHODS: The research consisted of a retrospective study of a group of 171 consecutive patients with mitral regurgitation and preoperative PH who had undergone mitral valve surgery between January 2008 and October 2011. The PH diagnosis was based on echocardiographic evidence (systolic pulmonary artery pressure [sPAP] >35 mm Hg). The echocardiographic examination included assessment of the following: LV volume, LV ejection fraction (LVEF), sPAP, right ventricular end-diastolic diameter, right atrium area indexed to the body surface area, the ratio of the pulmonary acceleration time to the pulmonary ejection time (PAT/PET), tricuspid annular plane systolic excursion (TAPSE), determination of the severity of the associated tricuspid regurgitation, and presence of pericardial fluid. Surgical procedures consisted of mitral valve repair in 55% of the cases and mitral valve replacement in the remaining 45%. Concomitant coronary artery bypass grafting (CABG) surgery was carried out in 52 patients (30.41%), and De Vega tricuspid annuloplasty was performed in 29 patients (16.95%). The primary end point was perioperative mortality. The secondary end points included the following: pericardial, pleural, hepatic, or renal complications; the need for a new surgical procedure; postoperative mechanical ventilation >24 hours; length of stay in the intensive care unit; duration of postoperative inotropic support; need for an intra-aortic balloon pump; and need for pulmonary vasodilator drugs. RESULTS: The mortality rate was 2.34%. In the univariate analysis, the clinical and echocardiographic parameters associated with mortality were preoperative New York Heart Association (NYHA) class IV, the PAT/PET ratio, TAPSE, the indexed area of the right atrium, and concomitant CABG surgery. In the multivariate analysis, the indexed area of the right atrium and concomitant CABG surgery remained statistically significant. The multivariate analysis also showed the indexed area of the right atrium, LVEF, presence of pericardial fluid, preoperative NYHA class, and concomitant CABG surgery as statistically significant for the secondary end point. The receiver operating characteristic (ROC) curves identified an sPAP value >65 mm Hg to have the highest specificity and sensitivity for the risk of perioperative death in mitral regurgitation patients (area under the ROC curve [AUC], 0.782; P < .001) and identified an sPAP value of 60 mm Hg as the secondary end point (AUC, 0.82; P < .001). Severe PH (sPAP >60 mm Hg) is associated with a significant increase in the mortality rate; a longer stay in the intensive care unit; a mechanical ventilation duration >24 hours; lengthy inotropic support; renal, hepatic, and pericardial complications; and a need for endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and/or prostanoids, both in the general group and in patients with preserved systolic functioning of the left ventricle. CONCLUSIONS: PH is a strong short-term negative prognostic factor for patients with mitral regurgitation. The surgical procedure should be performed in the early stages of PH. Echocardiographic examination has useful, simple, and reproducible tools for classifying operative risks. An ischemic etiology and a need for concomitant CABG surgery are additional risk factors for patients with mitral regurgitation and PH.

Risk factors associated with intra-stent restenosis after percutaneous coronary intervention.

The present study aimed to explore the correlations between clinical, biological, imagistic and procedural factors with the risk of intra-stent restenosis (ISR) in coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI). An observational cross-sectional study was conducted in a high-volume PCI center over a period of 2 years. A total of 235 consecutive patients diagnosed with angina or acute coronary syndrome treated by PCI were included in the study. Diagnosis of ISR was documented by coronary angiography in patients with suggestive coronary symptoms and ischemic changes in non-invasive or invasive paraclinical investigations. Thus, they were assigned to two groups: With or without ISR. All patients underwent clinical and laboratory examination, providing clinical and paraclinical variables that could be considered risk factors for ISR. Current smokers [risk ratio (RR)=1.63; 95% confidence interval (95% CI): 1.25-2.13], arterial hypertension (RR=1.86; 95% CI: 1.41-2.45), diabetes (RR=1.83; 95% CI: 1.42-2.36), high C-reactive protein (CRP) levels (RR=1.44; 95% CI: 0.93-2.24), chronic kidney disease (CKD) (RR=1.90; 95% CI: 1.53-2.36) and thrombolysis in myocardial infarction (TIMI) score were found to have a significant role in estimating the risk for ISR. Moreover, the ISR group (119 patients) presented with a lower stent inflation pressure when compared to the control group (116 patients) (14.47 vs. 16.14 mmHg, P=0.004). An increased mean stent diameter used for PCI was not associated with a high ISR incidence (P=0.810) as well as complex coronary treated lesions with longer stents (mean length of 24.98 mm in patients without ISR vs. 25.22 mm in patients with ISR; P=0.311). There was an estimated two times higher risk (RR=2.13; 95% CI: 1.17-3.88) concerning multi-stenting and restenosis degree >70%. To conclude, smoking, hypertension, diabetes mellitus, high CRP levels, CKD, TIMI score, stent type, low pressure for stent implantation and multi-stenting were found to be associated with ISR in patients following PCI. Therefore, a close follow-up should be targeted in such patients.

Angiotensin-converting enzyme gene D-allele and the severity of coronary artery disease.

Coronary artery disease (CAD) is the first cause of morbidity and mortality worldwide. An important goal is to diagnose patients in early stages, in order to reduce acute cardiovascular events. The angiotensin-converting enzyme (ACE) is an important element for the cardiovascular system, through its actions on hydro-salin balance and vascular tone. ACE polymorphism consists of insertions (I)/deletions (D) and there are 3 genotypes: II, ID, DD. It is speculated that the DD genotype may be a genetic basis for severe CAD, while the II genotype may have a protective effect on the coronary arteries. The present study included 154 patients with acute coronary syndroms admitted to the Institute for Cardiovascular Disease 'George I.M. Georgescu', Iasi. The patients underwent coronary angiography in order to assess the severity of the lesions and the ACE genotypes were determined for each patient. The genotypes were correlated with the severity of the vessel-disease and the exposure to classic risk factors. It was concluded that the D-allele is associated with a greater risk for acute coronary events and severe coronary stenosis, especially when risk genotype and risk phenotype interact.

Abnormal atrioventricular node conduction and atrioventricular nodal reentrant tachycardia in patients older versus younger than 65 years of age.

STUDY OBJECTIVE: We examined the possible role of atrioventricular node (AVN) conduction abnormalities as a cause of AVN reentrant tachycardia (RT) in patients >65 years of age. STUDY POPULATION: Slow pathway radiofrequency catheter ablation (RFCA) was performed in 104 patients. Patients in group 1 (n = 14) were >65 years of age and had AV conduction abnormalities associated with structural heart disease. Patients in group 2 (n = 90) were <65 years of age and had lone AVNRT. RESULTS: Patients in group 1 versus group 2 (66% vs. 46% men) had a first episode of tachycardia at an older age than in group 2 (68 +/- 16.8 vs 32.5 +/- 18.8 years, P = 0.007). The history of arrhythmia was shorter in group 1 (5.4 +/- 3.8 vs 17.5 +/- 14, P = 0.05) and was associated with a higher proportion of patients with underlying heart disease than in group 2 (79% vs 3%, P < 0.001). The electrophysiological measurements were significantly shorter in group 2: atrial-His interval (74 +/- 17 vs 144 +/- 44 ms, P = 0.005), His-ventricular (HV) interval (41 +/- 5 vs 57 +/- 7 ms, P = 0.001), Wenckebach cycle length (329 +/- 38 vs 436 +/- 90 ms, P = 0.001), slow pathway effective refractory period (268 +/- 7 vs 344 +/- 94 ms, P = 0.005), and tachycardia cycle length (332 +/- 53 vs 426 +/- 56 ms, P = 0.001). The ventriculoatrial block cycle length was similar in both groups. The immediate procedural success rate was 100% in both groups, and no complication was observed in either group. One patient in group 2 had recurrence of AVNRT. One patient with a 98-ms HV interval underwent permanent VVI pacemaker implantation before RFCA procedure. CONCLUSION: In patients undergoing RFCA for AVNRT at >65 years of age had a shorter history of tachycardia-related symptoms than patients with lone AVNRT. The longer AVN conduction intervals and refractory period might explain the late development of AVNRT in group 1.

The Patterns of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) Use in Patients with Atrial Fibrillation in Seven Balkan Countries: a Report from the BALKAN-AF Survey.

INTRODUCTION: Data on management of atrial fibrillation (AF) in the Balkan Region are scarce. To capture the patterns in AF management in contemporary clinical practice in the Balkan countries a prospective survey was conducted between December 2014 and February 2015, and we report results pertinent to the use of non-vitamin K antagonist oral anticoagulants (NOACs). METHODS: A 14-week prospective, multicenter survey of consecutive AF patients seen by cardiologists or internal medicine specialists was conducted in Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, Romania, and Serbia (a total of about 50 million inhabitants). RESULTS: Of 2712 enrolled patients, 2663 (98.2%) had complete data relevant to oral anticoagulant (OAC) use (mean age 69.1 ± 10.9 years, female 44.6%). Overall, OAC was used in 1960 patients (73.6%) of whom 338 (17.2%) received NOACs. Malignancy [odds ratio (OR), 95% confidence interval (CI) 2.06, 1.20-3.56], rhythm control (OR 1.64, 1.25-2.16), and treatment by cardiologists were independent predictors of NOAC use (OR 2.32, 1.51-3.54) [all p < 0.01)], whilst heart failure and valvular disease were negatively associated with NOAC use (both p < 0.01). Individual stroke and bleeding risk were not significantly associated with NOAC use on multivariate analysis. CONCLUSIONS: NOACs are increasingly used in AF patients in the Balkan Region, but NOAC use is predominantly guided by factors other than evidence-based decision-making (e.g., drug availability on the market or reimbursement policy). Efforts are needed to establish an evidence-based approach to OAC selection and to facilitate the optimal use of OAC, thus improving the outcomes in AF patients in this large region.

[Myeloid metaplasia with myelofibrosis associated with acute coronary syndrome. Case report]. / Metaplazia mieloida cu mielofibroza complicata cu sindrom coronarian acut.

A 66-year-old man with myelofibrosis and myeloid metaplasia was admitted to hospital where he was diagnosed with acute coronary syndrome. Percutaneous transluminal coronary recanalization followed by drug-eluting stenting resulted in successful revascularization. Because besides thrombus formation the myeloproliferative syndrome has a potential for bleeding, it is very important to carefully follow-up any clotting abnormality.

[Comparative efficiency of externally-irrigated cooled-tip catheter vs. 8-mm-tip catheters in radiofrequency (RF) ablation of common atrial flutter]. / Eficacitatea comparativa a cateterului de irigatie externa versus cateter de 8 mm in ablatia prin radiofrecventa a flutterului atrial istmic.

UNLABELLED: Cooled-tip and 8-mm-tip catheters have been found to be more effective than conventional 4-mm-tip catheters for radiofrequency (RF) ablation of common atrial flutter. The aim of this study was retrospective comparison between cooled-tip and and 8-mm-tip catheters in terms of efficacy and safety of RF ablation in atrial flutter. MATERIAL AND METHOD: Among 148 consecutive patients (pts) referred for common atrial flutter, cavotricuspid ablation was performed with an externally-irrigated cool tip catheter in 100 pts, and with an 8-mm-tip ablation catheter in 48 patients. RF current was applied for 60 seconds at powers of 50 W with the cooled-tip catheter, and in a temperature-controlled mode (65 degrees C/70 W) with the 8-mm-tip catheter, until bidirectional isthmus block was reached, or a total of 35 unsuccessful RF applications were performed. RESULTS: A higher initial failure rate with 8-mm-tip catheters was significant, compared to the externally-irrigated catheter (18% vs 4% ; p < 0.01). Significant differences were also found in some procedure parameters, such as the number of RF applications (26 +/- 8 vs 35 +/- 10; p < 0.04), fluoroscopy time (11 +/- 15 min vs 27 +/- 10 min; p < 0.01) and total procedure duration (95 +/- 23 min vs 145 +/- 35 min; p < 0.09). No major complications occurred. In a mean follow-up of 30 +/- 11 months atrial flutter recurred only in group treated with 8 mm catheter (10 patients among 48). CONCLUSION: In achieving cavotricuspid isthmus block, RF ablation performed through cooled-tip catheters is more efficient than application through 8-mm-tip catheters.

[Effectiveness of prostaglandin treatment in idiopathic pulmonary hypertension]. / Eficienta tratamentului cu prostaglandine in hipertensiunea pulmonara idiopatica.

UNLABELLED: Calcium channel blockers are the only vasodilators that proved their efficiency in idiopathic pulmonary hypertension (IPH). However, not every patient is responsive to this therapy. Only in isolated cases of IPH was proved the good effect of prostaglandins in lowering the pulmonary pressure by inhibiting the proliferation of smooth muscle cells. The follow up of a patient, male, 66 years, with IPH, NYHA IV class global cardiac decompensation, mostly the right heart, cyanotic, with 85% SaO2 at rest, massive edema, with "hair cut" aspect of pulmonary circulation, cardiomegaly assessed radiologically (CTI 0.55) and echocardiographically (important dilation of right heart chambers, RV 50/44 mm, compressing the left heart chambers, IVth grade tricuspid insufficiency and 160/90 mmHg pulmonary pressure) is presented. It was excluded a secondary cause of pulmonary hypertension, both by echocardiography and by cardiac catheterization, which eventually confirms the angiographic diagnosis of IPH (dilation of pulmonary artery and its branches, with no peripheral circulation). The progress was spectacular after introducing iloprost as therapy (two i.v. sessions at one month interval (28 days))--excellent clinical amelioration until IInd NYHA class, 96% SaO2 at rest, disappearance of pleural and pericardial effusion, with the diminishing of heart dimensions in radiological (CTI 0.44) and echography exams (RV 46/38 mm), amelioration of tricuspid regurgitation (grade II) and also the significant decrease of pulmonary pressure (90/60 mmHg). CONCLUSION: The therapy with iloprost is particularly effective in treating IPH.

Does treatment with ACE inhibitors prevent the long term recurrences of lone atrial fibrillation after cardioversion?

UNLABELLED: This study aimed to prove that angiotensin-converting enzyme inhibitor (ACEI) could improve sinus rhythm maintenance after conversion of atrial fibrillation (AF). METHODS AND RESULTS: A study of 36 patients with lone AF who undertook electrical conversion was conducted. Group 1 included 20 patients treated exclusively with a class I C antiarrhythmic (Propafenona, 450 mg daily) and group 2 included 16 patients treated with antiarrhythmic plus ACEI after cardioversion. These two groups were comparable, with mean age 56.2+/-11.8 vs. 57.7+/-6.1 years (P 0.709), onset of AF 2.47+/-3.72 vs. 5.5+/-7.37 months (P 0.205) and echocardiografic parameters: left atrium diameter 45.1+/-5.8 vs. 45.0+/-6.1 mm (P 0.995); LVTDV 48.5+/-5.0 vs. 48.6+/-6.4 mm (P 0.998); LVTSV 35.1+/-5.0 vs. 36.0+/-7.0 mm (P 0.737) and EF 59.0+/-6.9% vs. 54.8+/-6.1% (P 0.135). The patients were followed up clinically and electrocardiographically 12 months after conversion. Kaplan-Meier analysis showed a higher probability of remaining in sinus rhythm one year after cardioversion for group 2 compared to group 1 (37.5% vs. 20%). The mean time interval for the appearance of recurrences was significantly higher in patients treated with ACEI and antiarrhythmics compared to the patients treated only with antiarrhythmics (7.06+/-1.02 vs. 4.50+/-0.93 months; Breslow test (generalized Wilcoxon) - 4.473, P 0.034). CONCLUSION: The addition of ACEI to an antiarrhythmic decreases the rate of AF recurrences and facilitates the maintenance of sinus rhythm after cardioversion.

[Effectiveness of angiotensin-converting enzyme inhibitors in the maintenance of sinus rythm after conversion of arterial fibrillation]. / Eficienta inhibitorilor enzimei de conversie a angiotensinei în mentinerea ritmului sinusal post-conversie a fibrilatiei atriale.

UNLABELLED: This study aimed to prove that angiotensin-converting enzyme inhibitors (ACEI) could improve sinus rhythm maintenance after electrical or chemical conversion of atrial fibrillation (AF). METHODS: A prospective study of 36 patients with lone AF which undertook chemical or electrical conversion was conducted. Group 1 included 20 patients treated exclusively with a class I C antiarrhythmic (Propafenone, 450 mg daily) and group 2 included 16 patients treated with antiarrhythmic plus ACEI pre- and after cardioversion. RESULTS: These two groups were comparable, with mean age 56.2 +/- 11.8 vs. 57.7 +/- 6.1 years (P 0.709), onset of AF 2.47 +/- 3.72 vs. 5.5 +/- 7.37 months (P 0.205) and echocardiographic parameters: left atrium diameter 45.1 +/- 5.8 vs. 45.0 +/- 6.1 mm (P 0.995); LVTDV 48.5 +/- 5.0 vs. 48.6 +/- 6.4 mm (P 0.998); LVTSV 35.1 +/- 5.0 vs. 36.0 +/- 7.0 mm (P 0.737) and EF 59.0 +/- 6.9% vs. 54.8 +/- 6.1% (P 0.135). The patients were followed up clinically and electrocardiographically 12 months after conversion. Kaplan-Meier analysis showed a higher probability of remaining in sinus rhythm one year after cardioversion for group 2 compared to group 1 (37.5% vs. 20%). The mean time interval for the appearance of recurrences was significantly higher in patients treated with ACEI and antiarrhythmics compared to the patients treated only with antiarrhythmics (7.06 +/- 1.02 vs. 4.50 +/- 0.93 months; Breslow test (generalized Wilcoxon)--4.473, P 0.034). CONCLUSION: The addition of ACEI to an antiarrhythmic decreases the rate of AF recurrences and facilitates the maintenance of sinus rhythm after cardioversion.